APTA has learned that a letter issued by the Centers for Medicare and Medicaid Services (CMS) about the therapy cap has caused some beneficiaries to panic and cancel appointments.

CMS recently began issuing letters to Medicare beneficiaries who have received $1,700 or more in outpatient therapy services in calendar 2012. The letter informs beneficiaries that if services are furnished above the therapy cap of $1,880 in 2012, and the requirements for an exception are not met, then the beneficiary would be financially responsibility for these services.

To help ease beneficiaries' concerns, APTA has developed a frequently-asked-questions (FAQs) document that physical therapists can download and distribute to patients. Additionally, the document can be accessed by patients directly from APTA's Move Forward consumer website.

Comments

I appreciate the effort to ease beneficiaries' concerns about the CMS letter, thank you for taking the time to do this!
I do wish that you would consider adding more about medical necessity, using CMS' rationale so that the patients don't think we can just add the KX and get paid. I believe patients need to understand that there is a limit to everything and that their active participation (i.e. progression) in their therapy is paramount. Additionally, they need to understand what is involved with justifying the exception...co-morbidities, social and environmental challenges exceeding the norm, functional not recreational limitation, etc.. All patients believe their care IS medically necessary! I believe that in many cases it is, indeed, medically indicated but just not medically necessary per the payers requirements.
Mary

Posted by Mary Daulong
on 9/7/2012 6:02 PM

I agree with Mary D's comment. I was worried when I read the APTA FAQ since it sorely understated the issue of medical necessity. I understand that explaining these issues to patients is part of my responsibility as a therapist but I think information put out by our organization should be more thorough. As it reads, the patient could come away thinking that their PT can easily "obtain" an exception to the cap just by using a "special code." Please amend the FAQ to include more information defining "medical necessity."
Patients need to have a better understanding of the very complicated insurance issues so that they can make better informed choices when choosing people and ideas that will represent them in both local and national politics.

Posted by Michelle Spicher
on 9/8/2012 12:08 AM

I commend the APTA for developing this FAQ document in response to the recent CMS letter. It is concise and simple for patients to understand. This document also allows patients to see that we, as clinicians, have support from our national professional organization in offering them potential choices for additional care beyond an arbitrary "cap" if deemed medically necessary. This will certainly encourage dialogue between the patient and therapist to discuss further details regarding the appropriateness of the cap exception for their particular situation. Then it is up to us to advocate for them as needed.
Don Freehafer,PT
FREEDOM PHYSICAL THERAPY
www.freedom-pt.com

Posted by Don Freehafer,PT
on 9/8/2012 8:40 AM

Thank you APTA for the helpful documents, including the patient petition. We can help our paients realize that they must advocate for their own health care and talk to their representatives about repealing the caps. I spoke with a patient who was crying about the letter from CMS because she wants so desperately to continue her physical therapy. She had a second orthopedic surgery this year, in July, followed by a stroke 2 weeks after surgery. She said she wouldn't be able to be home and able to walk if it hadn't been for working with her PT this last month. I encouraged her to continue and to not feel invalidated by the letter. I look forward to sharing the APTA letter and information with her this week so she will feel the support to keep working on her recovery. I encourage therapists to continue to document the skilled therapy they do every day with their patients so the medical necessity of our work is self evident.

Posted by Laura Bennetts MS PT
on 9/9/2012 3:15 PM

First of all, I would clarify the "cap" is $3700 before physical therapy services would need further extension (at least I understood that way)involving CMS decision makers.
I do believe only small number of patients with severe conditions would require our service beyond the established amount. I would agree it is arbitrary and we should prove beyond any doubts that our service is beneficiary to those who need us and CMS should not put any restrictions if those in need would require physical therapy services. Unless CMS believes monetary aspect overweight human desire to the best care elderly people deserve after many years of giving the best and building our wonderful country where people from CMS and us enjoy living.
Let's continue the dialogue with CMS and provide them many proofs our services are necessary and self evident.

Posted by Peter Kluba DPT
on 9/9/2012 7:36 PM

APTA has made a change to the letter posted September 7 to more explicitly encourage patients to talk with their physical therapists about “medical necessity.” The concept of medical necessity is complicated and not easily defined in a document that is intended to provide basic facts about the cap and serve as a conversation starter between patients and physical therapists.